Sugar SubstitutesSugar SubstitutesNon-cariogenic SweetenersNon-cariogenic Sweeteners

Dr.Ghada MaghairehDr.Ghada MaghairehBDS,MS,ABODBDS,MS,ABOD

Non-cariogenic Non-cariogenic SweetenersSweeteners

Sugar in sticky foods consumed between Sugar in sticky foods consumed between meals is associated with high caries meals is associated with high caries activity.activity.

These findings stimulated research on These findings stimulated research on hypoacidogenic and non-acidogenic sugar hypoacidogenic and non-acidogenic sugar substitutes that do not cause pH falls in substitutes that do not cause pH falls in dental plaque.dental plaque.

The usefulness of sugar substitute has to The usefulness of sugar substitute has to be looked upon not only from a cariological be looked upon not only from a cariological but also from nutritional, toxicological, but also from nutritional, toxicological, economic and technical point of view.economic and technical point of view.

Non-cariogenic Non-cariogenic SweetenersSweeteners

The most important issues to consider The most important issues to consider when evaluating a non-sugar sweetener in when evaluating a non-sugar sweetener in relation to dental caries are:relation to dental caries are:

1. Metabolism by oral microorganisms and 1. Metabolism by oral microorganisms and dental plaque.dental plaque. 2. The influence on cariogenic 2. The influence on cariogenic

microorganisms.microorganisms. 3. The risk of microbial adaptation to the 3. The risk of microbial adaptation to the sweetener. sweetener.

Types of Sugar Types of Sugar SubstitutesSubstitutes

Sugar substitutes can be separated Sugar substitutes can be separated into two major groups:into two major groups:

(I) Intense sweeteners (I) Intense sweeteners (II) Bulk sweeteners(II) Bulk sweeteners

Intense SweetenerIntense Sweetener There are many natural and synthesized There are many natural and synthesized

intense sweeteners.intense sweeteners. Some have very intense sweet taste, up to Some have very intense sweet taste, up to

several thousands as sweet as sucrose.several thousands as sweet as sucrose. Glyrrihizin, monellin, thumatin and Glyrrihizin, monellin, thumatin and

mirakulin are examples of naturally mirakulin are examples of naturally occurring intense sweeteners.occurring intense sweeteners.

The sweeteners alitam and aspartame are The sweeteners alitam and aspartame are based on amino acids or peptides.based on amino acids or peptides.

Intense SweetenerIntense Sweetener

Acesulfame-K, cyklamate, saccharin and Acesulfame-K, cyklamate, saccharin and sucralose are chemically synthesized sucralose are chemically synthesized sweeteners.sweeteners.

Intense sweeteners are used in a variety of Intense sweeteners are used in a variety of food products, dentifrices and in sweetening food products, dentifrices and in sweetening drops and tablets for use in food, coffee, tea, drops and tablets for use in food, coffee, tea, etc.etc.

Currently about 30% of the carbonated Currently about 30% of the carbonated beverages consumed in USA sweetened with beverages consumed in USA sweetened with aspartame.aspartame.

Intense SweetenerIntense Sweetener Intense sweeteners are not metabolized to Intense sweeteners are not metabolized to

acids by oral microorganisms.acids by oral microorganisms. Limitations of those sweeteners include Limitations of those sweeteners include

poor taste quality, instability and lack of poor taste quality, instability and lack of volume.volume.

It is important also to remember that other It is important also to remember that other ingredients, such as citric acid or ingredients, such as citric acid or phosphoric acid may cause dental erosion.phosphoric acid may cause dental erosion.

In some products, the naturally occurring In some products, the naturally occurring sugar may cause caries (e.g. fruit-flavored sugar may cause caries (e.g. fruit-flavored soft drinks).soft drinks).

Safety Concerns of Intense Safety Concerns of Intense SweetenersSweeteners

Few side-effects of intense sweeteners Few side-effects of intense sweeteners have been reported in human.have been reported in human.

The food label must declare if a product The food label must declare if a product contains a sweetener.contains a sweetener.

In the case of aspartame, the label must In the case of aspartame, the label must also say that the product contains a also say that the product contains a source of phenylalanine, because some source of phenylalanine, because some individuals are unable to metabolize this individuals are unable to metabolize this amino acid (i.e. those with amino acid (i.e. those with phenylketonuria).phenylketonuria).

Bulk SweetenersBulk Sweeteners An example of bulk sweeteners are sugar An example of bulk sweeteners are sugar

alcohols such as sorbitol and xylitol.alcohols such as sorbitol and xylitol. They are currently used in confectionary, They are currently used in confectionary,

chewing gum, chocolate, jellies and other chewing gum, chocolate, jellies and other sweets.sweets.

They are only partially absorbed in the small They are only partially absorbed in the small intestine and pass to the colon where they may intestine and pass to the colon where they may cause osmotic diarrhea.cause osmotic diarrhea.

They are not recommended in children under 3 They are not recommended in children under 3 years of age and may cause stomach problems if years of age and may cause stomach problems if they used in sugar-free medicine if the daily they used in sugar-free medicine if the daily intake is high.intake is high.

SorbitolSorbitol Sorbitol is a six-carbon sugar alcohol Sorbitol is a six-carbon sugar alcohol

that can not be utilized by the that can not be utilized by the microorganisms that dominate in the microorganisms that dominate in the dental plaque.dental plaque.

However, majority of strains of mutans However, majority of strains of mutans streptococci and lactobacilli do ferment streptococci and lactobacilli do ferment sorbitol which may limit its value as a sorbitol which may limit its value as a non-cariogenic sugar substitute.non-cariogenic sugar substitute.

There are fundamentals differences There are fundamentals differences between the fermentation of sucrose between the fermentation of sucrose and that that of sorbitol by S. mutans.and that that of sorbitol by S. mutans.

SorbitolSorbitol First, the fermentation of sorbitol proceeds at First, the fermentation of sorbitol proceeds at

slow rate and the final pH dose not reach slow rate and the final pH dose not reach such low levels seen with glucose or sucrose.such low levels seen with glucose or sucrose.

Secondly, sorbitol is metabolized by enzymes Secondly, sorbitol is metabolized by enzymes which are synthesized only when the bacteria which are synthesized only when the bacteria is exposed to sorbitol for a sufficient period.is exposed to sorbitol for a sufficient period.

Thirdly, fermentation of sorbitol yields Thirdly, fermentation of sorbitol yields considerable amounts of ethanol and formate considerable amounts of ethanol and formate but a small proportion of lactic acid.but a small proportion of lactic acid.

SorbitolSorbitol Many studies found that plaque pH Many studies found that plaque pH

drops only marginally and that a drops only marginally and that a critical pH of less than 5.7 is very critical pH of less than 5.7 is very seldom obtained in dental plaque seldom obtained in dental plaque following sorbitol consumption.following sorbitol consumption.

It has been concluded that the It has been concluded that the potential hypoacidogenic properties potential hypoacidogenic properties of sorbitol do not pose a cariogenic of sorbitol do not pose a cariogenic threat to the majority of people. threat to the majority of people.

XylitolXylitol Xylitol is a sugar alcohol with five Xylitol is a sugar alcohol with five

carbons that is not fermented by oral carbons that is not fermented by oral microorganisms.microorganisms.

Xylitol dose not lower the pH of the Xylitol dose not lower the pH of the dental plaque.dental plaque.

Xylitol has a bacteriostatic effect on Xylitol has a bacteriostatic effect on mutans streptococci.mutans streptococci.

Xylitol has the ability to reduce the Xylitol has the ability to reduce the population of mutans streptococci.population of mutans streptococci.

Other Bulk SweetenersOther Bulk Sweeteners Lycasin, maltitol and mannitol.Lycasin, maltitol and mannitol. Studies have indicated that these Studies have indicated that these

sweeteners have a low cariogenic sweeteners have a low cariogenic potential.potential.

Lycasin is a hydrogenated starch Lycasin is a hydrogenated starch hydrolysate.hydrolysate.

Various types have been manufactured by Various types have been manufactured by most lycacin products contain over 50% most lycacin products contain over 50% maltitol and low proportion of maltitol and low proportion of carbohydrates.carbohydrates.

Other Bulk SweetenersOther Bulk Sweeteners

Maltitol is a 12-carbon sugar.Maltitol is a 12-carbon sugar. Maltitol can be metabolized by Maltitol can be metabolized by

mutans streptococci, mutans streptococci, ActinomycesActinomyces and Lactobacilli at a slow rate.and Lactobacilli at a slow rate.

Maltitol dose not significantly lower Maltitol dose not significantly lower plaque pH.plaque pH.

Other Bulk SweetenersOther Bulk Sweeteners Mannitol, like sorbitol, is a six-Mannitol, like sorbitol, is a six-

carbon sugar alcohol.carbon sugar alcohol. Lactobacilli and mutans streptococci Lactobacilli and mutans streptococci

can ferment mannitol.can ferment mannitol. Mannitol gives only a small or no Mannitol gives only a small or no

decrease in plaque pH compared decrease in plaque pH compared with sucrose .with sucrose .

Use of non-sugar sweeteners Use of non-sugar sweeteners for caries preventionfor caries prevention

The most important goal of preventive dentistry The most important goal of preventive dentistry is to reduce the consumption of sweet products is to reduce the consumption of sweet products to a minimum which may be difficult to achieve.to a minimum which may be difficult to achieve.

Use of intense and bulk sweeteners can be Use of intense and bulk sweeteners can be accepted from toxicological and nutritional accepted from toxicological and nutritional point of view in certain risk products that are point of view in certain risk products that are used very frequently (e.g. chewing gum, used very frequently (e.g. chewing gum, confectionery, medicine and beverages).confectionery, medicine and beverages).

In chewing gums and confectionery, the caries-In chewing gums and confectionery, the caries-reducing effect can be expected to be 20-40% reducing effect can be expected to be 20-40% depending on the intake frequency of the depending on the intake frequency of the sugar-free products and the caries activity.sugar-free products and the caries activity.